ABSTRACT To outline the development and content of a 'top-up' neuropharmacology module for mental health nurse prescribers and consider how much pharmacology training is required to ensure effective mental health prescribing practice.
Debate about the content of prescribing training courses has persisted within the United Kingdom since the mid-1980s. In early 2003 supplementary prescribing was introduced and gave mental health nurses the opportunity to become prescribers. The challenge of the nurse prescribing curriculum for universities is that they have only a short time to provide nurses from a range of backgrounds with enough knowledge to ensure that they meet agreed levels of competency for safe prescribing. There is growing concern within mental health care that the prescribing of medication in mental health services falls short of what would be deemed good practice. Over the past two decades, nurse training has increasingly adopted a psychosocial approach to nursing care raising concerns that, although nurses attending prescribing training may be able to communicate effectively with service users, they may lack the basic knowledge of biology and pharmacology to make effective decisions about medication.
Following the completion of a general nurse prescribing course, mental health nurses who attended were asked to identify their specific needs during the evaluation phase. Although they had covered basic pharmacological principles in their training, they stated that they needed more specific information about drugs used in mental health; particularly how to select appropriate drug treatments for mental health conditions. This paper describes how the nurses were involved in the design of a specific module which would enable them to transfer their theoretical leaning to practice and in so doing increase their confidence in their new roles.
The findings of this study suggest that the understanding and confidence of mental health nurse prescribers about the drugs they prescribe coupled with the information they provide to service users can be improved as a result of specific educational support. It would appear that adopting a prescribing dimension to one's role requires nurses to revisit a number of skills that are integral to the work of the mental health nurse, e.g. good communication, establishing empathy, listening to what clients say, responding to what is required and involving clients in their own care.
Mental health nurses from one particular Trust in the West Midlands were provided with a 'top-up' course in neuropharmacology and, although they found this challenging, ultimately they found this to be helpful. As nurse prescribing is 'rolled out' to other nursing specialities it is important that local Trusts and Workforce Development Directorates maintain a dialogue about nurse prescriber training to ensure that nurse prescribers receive the appropriate time and support for their ongoing Continued Professional Development. As increasing numbers of nurses from different specialities qualify as nurse prescribers it is vital that they are supported by their employing organizations and given the opportunity to maintain their competency and confidence in their prescribing practice.

Full-text

MENTAL HEALTHdoi: 10.1111/j.1365-2702.2006.01378.xNeuropharmacology and mental health nurse prescribersDavid Skingsley BSc, PgCertTHE, DPhil, FRESSenior Lecturer, Faculty of Health & Sciences, Staffordshire University, Stafford, UKEleanor J Bradley BSc, MSc, PhD, CPsycholReader in Mental Health, Faculty of Health & Sciences, Staffordshire University, Stafford, UKPeter Nolan BA, BEd, MEd, PhD, RMN, RGN, DN, RNTProfessor of Mental Health Nursing, Faculty of Health and Sciences, Staffordshire University, Stafford, UKSubmitted for publication: 14 September 2004Accepted for publication: 26 July 2005Correspondence:Peter NolanFaculty of Health and SciencesStaffordshire UniversityBlackheath LaneStafford ST18 0AD, UKTelephone: 01785 353702E-mail: p.w.nolan@staffs.ac.ukSKINGSLEY D, BRADLEY EJ & NOLAN P (2006) SKINGSLEY D, BRADLEY EJ & NOLAN P (2006)989–997Neuropharmacology and mental health nurse prescribersAims and objectives. To outline the development and content of a ‘top-up’ neuro-pharmacology module for mental health nurse prescribers and consider how muchpharmacology training is required to ensure effective mental health prescribingpractice.Background. Debate about the content of prescribing training courses has persistedwithin the United Kingdom since the mid-1980s. In early 2003 supplementaryprescribing was introduced and gave mental health nurses the opportunity tobecome prescribers. The challenge of the nurse prescribing curriculum for univer-sities is that they have only a short time to provide nurses from a range of back-grounds with enough knowledge to ensure that they meet agreed levels ofcompetency for safe prescribing. There is growing concern within mental health carethat the prescribing of medication in mental health services falls short of whatwould be deemed good practice. Over the past two decades, nurse training hasincreasingly adopted a psychosocial approach to nursing care raising concerns that,although nurses attending prescribing training may be able to communicateeffectively with service users, they may lack the basic knowledge of biology andpharmacology to make effective decisions about medication.Methods. Following the completion of a general nurse prescribing course, mentalhealth nurses who attended were asked to identify their specific needs during theevaluation phase. Although they had covered basic pharmacological principles intheir training, they stated that they needed more specific information about drugsused in mental health; particularly how to select appropriate drug treatments formental health conditions. This paper describes how the nurses were involved in thedesign of a specific module which would enable them to transfer their theoreticalleaning to practice and in so doing increase their confidence in their new roles.Results. The findings of this study suggest that the understanding and confidence ofmental health nurse prescribers about the drugs they prescribe coupled with theinformation they provide to service users can be improved as a result of specificeducational support. It would appear that adopting a prescribing dimension to one’srole requires nurses to revisit a number of skills that are integral to the work of themental health nurse, e.g. good communication, establishing empathy, listening toJournal of Clinical Nursing 15,? 2006 Blackwell Publishing Ltd989

Page 2

what clients say, responding to what is required and involving clients in their owncare.Conclusion. Mental health nurses from one particular Trust in the West Midlandswere provided with a ‘top-up’ course in neuropharmacology and, although theyfound this challenging, ultimately they found this to be helpful. As nurse prescribingis ‘rolled out’ to other nursing specialities it is important that local Trusts andWorkforce Development Directorates maintain a dialogue about nurse prescribertraining to ensure that nurse prescribers receive the appropriate time and support fortheir ongoing Continued Professional Development.Relevance to clinical practice. As increasing numbers of nurses from different spe-cialities qualify as nurse prescribers it is vital that they are supported by theiremploying organizations and given the opportunity to maintain their competencyand confidence in their prescribing practice.Key words: competency, education, mental health, neuropharmacology, supple-mentary nurse prescribingIntroductionIn the United Kingdom (UK), nurse prescribing has been onthe political agenda for almost two decades (Department ofHealth and Social Services 1986) and legislation was enactedin October 1994 permitting limited prescribing rights forHealth Visitors and District Nurses. Mental health nurses,however, are comparatively new to nurse prescribing. In2001, the nurse prescribing formulary (NPF) was extendedand the Nursing and Midwifery Council (NMC) respondedby outlining a curriculum for training for ‘extended formu-lary independent nurse prescribers’ (EFNPs). The length ofthe course was set at 25 days, plus 12 days learning inpractice under the supervision of a medical practitioner.EFNPs are restricted to prescribing items in the ExtendedNurse Prescribers’ Formulary (ENPF). In early 2003, supple-mentary prescribing was introduced. Supplementary pre-scribers can prescribe from the entire British NationalFormulary (BNF), with the exception of Controlled Drugs(mainly narcotics and drugs of addiction) and unlicensedmedicines, once a clinical management plan has beenestablished by the whole care team.Upon the introduction of supplementary prescribing, a‘dual-qualification’ was offered by Higher Education Institu-tions (HEIs) whereby nurses would receive the same curri-culum as per extended formulary nurse prescribing, with anadditional 1–2 days to cover supplementary prescribing.Most nurses now complete the entire course and, as such,become ‘dual qualified’ as EFNPs and supplementary nurseprescribers.The extension of nurse prescribing was offered partly as aresponse to a number of policy documents produced by theDepartment of Health (DoH) which hoped to encourage themodernization of the National Health Service (NHS),advance nursing roles, improve nurse education, increasepatient choice and improve access to services (DoH 1999,2001, 2002a). Expenditure on drugs currently represents thelargest proportion of UK NHS costs after staff (Chapman2004). Approximately half of all prescriptions are takenincorrectly (Audit Commission 2001). Fairman et al. (1998)suggest that there are considerable problems with theaccuracy of diagnoses and the subsequent appropriatenessof prescribing, while Isacsson et al. (1996) describe thedifficulties some prescribing clinicians have with formingrelationships with recipients. As nurses have more contactwith service users, as well as good communication skills, theyhave an important role in improving patients’ experiences ofhealth care and enhancing concordance (Pearce 2003).Although the DoH and the NMC provide guidelines touniversities for the nurse prescribing curriculum, eachuniversity has flexibility with regards to specific modulesand the assessments conducted. Flexibility is crucial to permituniversities to evaluate and redesign the curriculum in linewith feedback from nurse prescribers and to keep coursesrelevant to the local context. Organizations differ widelyacross the UK with regards to the support and preparationthey offer for nurse prescribing and it is important thatcourses are able to reflect these differences. Flexibility ofcourse content is also important as each cohort of nurses islikely to represent a number of different specialities andinclude nurses with varying amounts of experience and thosewho work in different settings.Good educational practice requires that universities workclosely with local trusts both in the design of courses and inD Skingsley et al.990? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997

Page 3

their delivery. One university in the West Midlands whichcollaborated closely with a mental health trust embraced thenurse prescribing initiative in early 2003. It was consideredimportant that the university should take into account theparticular challenges and issues that mental health nurseprescribers would face. This was achieved through rigorouscourse evaluation based on the requirements of nurseprescribers in practice. Course feedback indicated that mentalhealth nurses learned a great deal from training with othernurses from a variety of backgrounds and disciplines yet feltthey needed additional specific training to boost theirconfidence and prescribing skills.Prescribing is a multi-faceted activity, which requiresknowledge of biology, pharmacology and skills of commu-nication. The challenge of the nurse prescribing curriculumfor universities is that they have only a short time to providenurses, from a range of backgrounds, with enough knowledgeto ensure that they meet agreed levels of competency for safeprescribing. Nurses attending prescribing courses at threeuniversities across the West Midlands, UK were consulted aspart of course evaluations and asked to outline the areas inwhich they felt they needed the most training. Many hadconcerns about their lack of pharmacological knowledge,feeling that they would require considerable input in this areaduring training and ongoing support following qualification(Bradley et al. 2005). A group of mental health nurses,already qualified as prescribers, discussed their needs formore neuropharmacology training with senior personnelwithin their trust which subsequently led to an extra modulebeing provided at the local university. This paper will outlinethe development and content of this module and considerhow much pharmacology training is required to ensureeffective mental health nurse prescribing practice.Issues related to mental health prescribingThe concerns expressed by mental health nurse prescriberswould appear to be justified. A growing body of knowledge isrevealing that medical prescribing in mental health servicesfalls short of what would be deemed good practice. Pumar-iega and Winters (2003) argue that too much medication iscurrently used to support mental health clients to copesocially and psychologically in community settings. This, theycontend, masks the effects of other interventions and pointout that this is particularly the case in child and adolescentservices. Mental health prescribing may be particularlyproblematic because of a number of factors including therecent growth in medication options, the increasing com-plexity of pharmacological decision making, the mountingnumber of clients and the relatively short consultation timeavailable in which to identify problems. The current inad-equacy of medical prescribing in mental health brings intoquestion the appropriateness of introducing non-medicalprescribers to a field where prescribing errors are alreadyproblematic. Although many clients do benefit considerablyfrom psychotropic drugs, it must be borne in mind that otherclients do experience major problems, the most striking beingsudden death and the lengthening of the QT interval on theelectrocardiogram which may result in life-threateningarrhythmias (Pumariega & Winters 2003). Because theincidence of mortality is higher among psychiatric patientsthan among the general population Chong and Mythily(2001) recommend that all patients who are prescribedchlorpromazine and antipsychotic depot medication shouldbe regularly monitored with electrocardiograms.The use of polypharmacy is another cause of concern inmental health prescribing. In a study of acute inpatients,Paton et al. (2003) found that over 60% were prescribedatypical combined with typical antipsychotics and that largedoses of antipsychotics were frequently prescribed ‘asrequired’ and left to the discretion of nurses to administer.Over 70% of the sample were on other forms of medication.In attempting to identify the source of poor prescribingpractices, Senst et al. (2001) identified mental health care ashaving higher medication errors than any other branch ofhealth care. Most of these errors, they concluded, were costlyand often preventable. Nirodi and Mitchell (2002) examinedthe quality of 320 drug prescriptions by medical staff forolder hospitalized patients with dementia and found that20% were illegible, one-third contained missing informationon either dose, intended frequency or indications for use.Perhaps the most alarming finding was that only 20prescriptions were error-free and legible. However, as Laraia(2001) outlines, in many settings it is the mental health nursewho is responsible for administering each medication dose, aswell as being alert for adverse drug reactions and minimizingside effects. Furthermore, the mental health nurse has animportant role in co-ordinating treatment modalities and is ina position to integrate drug treatments with a wide range ofnon-pharmacological treatments in a manner that is safe andacceptable to the patient. The introduction of non-medicalprescribing, therefore, has the capacity to address concernsabout prescription errors in psychiatry and moreoverimprove the integration of services that clients receive.Although research carried out in the United States hasreported favourably on the mental health nurse prescribinginitiative, few studies have explored the emerging role of theadvanced practice psychiatric nurse with prescribing author-ity and there is little information available about theirpractice and training needs. Kaas and Markley (1998) haveMental healthMental health nurse prescribers? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997991

Page 4

suggested that this may be partly due to the diminishingnumber of these specialists and confusion around theintegration of neurobiological knowledge with nursingknowledge in the field of mental health. In the UK, theconcerns of mental health nurses about their future prescri-bing roles suggest that there are differences between mentalhealth nurses with prescribing authority and other nurses interms of their training needs and expectations. Doran (2003)contends that these concerns are justified and that prescribingmedication for mental health problems is more complex forboth patient and practitioner than prescribing antibiotics,analgesics, anti-hypertensives, cardiac and pulmonary medi-cation. He argues that the essence of prescribing is testinghypotheses about what the problem really is and decidingwhat will assist the person to get well. This process takes intoaccount that the same medication will affect people differ-ently, hence the importance of taking each person’s individ-ual circumstancesinto accountassessment. Trujillo (2001) identified further problems inthat prescribing clinicians in the field of mental healthoperated very differently from their colleagues in primarycare, which frequently led to very different types of medica-tion being prescribed for the same problem. Similar prescri-bing differences emerge in situations where one personprovides a range of therapeutic interventions compared withwhen a team is involved (Dewan 1999). The skill ofcombining different interventions is still largely underdevel-oped in some mental health services leaving healthcarepersonnel unsure about what treatments are effective(Kallertt & Leisse, 2001).Worldwide, the increasing incidence of mental healthproblems highlights the need for more mental health nurseprescribers to enable faster access to treatment and improvedconcordance. The successful management of conditions suchas depression, however, requires the mental health nurseprescriber to resolve a number of complex issues surroundingthe choice of treatment and the expectations of the serviceuser. In terms of pharmacological management of majordepression, there are a range of drugs available, includingTricyclic antidepressants (TCAs), second generation antide-pressants (Selective Serotonin Reuptake Inhibitors) andMonoamine Oxidase Inhibitors (MAOIs). These demonstratevarying effectiveness, potency and side effects and there arestill many unanswered questions, particularly regarding theeffectiveness and side effects of second generation antide-pressants (Frank & Kupfer 2000). Although SSRIs wereinitially thought to be free of side effects, it now appears thatthey simply have different adverse effect profiles from theolder TCAs and MAOIs. The pharmacological treatment ofdepression also requires a significant commitment fromwhen conductinganservice users (Frank & Kupfer 2000). Concordance withantidepressant medication is poor, with between 20% and59% of service users in primary care stopping their medica-tion within three weeks of it being prescribed (Johnson 1973,Thompson et al. 1982). Although drugs tend to be the first-line of treatment for depression, psychological approachessuch as cognitive behavioural therapy and humanisticapproaches are now recognized as vital tools to be used incombination with medication (Benefield & Ereshefsky 1994).Nurse prescribing training for mental healthnursesNurse prescribing courses are designed to provide a corecurriculum to nurses from different specialities, includingmental health and primary care. Feedback from mentalhealth nurses in the West Midlands suggests that, at thebeginning of the independent prescribing course, they feelthat the content is not relevant as the focus is largely on issuesin primary care. However, towards the end of the course,many have changed their minds and decided that the trainingadequately instructs them in general prescribing principlesand delivers knowledge that they can apply to mental healthpractice. Nonetheless, they feel that, overall, there is insuf-ficient attention paid to issues specific to mental healthnursing practice and that they need to complete furthermodules outside the core prescribing curriculum to ensuretheir competency. Such modules would benefit all nurseprescribers and, in particular, primary care nurses, as it hasbeen estimated that approximately 30% of patients present-ing in primary care have sufficient depressive characteristicsto meet the criteria for psychiatric morbidity, although theseare not always recognized (Rees et al. 1997). Nurse prescri-bing courses were originally designed to cover the four mainareas in which it was anticipated that independent nurseprescribers would be working, namely, minor illness, minorinjury, health promotion and palliative care. With extensionsto the NPF likely and an increasing number of supplementaryprescribers, it is important that prescribing courses movebeyond these areas. By 2020, depressive disorders are set tobecome the second most frequent cause of ill health world-wide (Brown 2001). Nurses from all specialities will becoming into contact with service users with mental healthproblems on an increasingly frequent basis.As well as having up-to-date knowledge of pharmacologi-cal approaches to mental health care, it is vital that mentalhealth nurse prescribers are able to take into account thecontext in which treatment is occurring (Bracken & Thomas2002). Assessment and diagnosis of mental health problemsare dependent, to a large degree, on autobiographical detailsD Skingsley et al.992? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997

Page 5

provided by the service user. The nurse prescriber will only beable to gain access to the ‘mental life’ of the service user, theirthoughts, beliefs and values if the service user is willing todivulge this information. To make decisions about treatment,the mental health nurse must elicit these thoughts and feelingsalongside details about family history and previous illnessepisodes. The expectations of the service user are particularlyimportant to the success of pharmacological treatments. Inthe case of depression, it is vital that people understand thatthey may experience side effects before they notice areduction in their symptoms. It has been suggested that thebest predictor of concordance is the extent to which serviceusers feel able to discuss treatment options with the prescri-bing professional and select those that best fit the context oftheir lives (Nolan & Badger 2002). On the contrary, poorrelationships between doctors and service users, exacerbatedby limited time available for the service user to tell their storyand elaborate concerns, may have a negative impact onconcordance with antidepressant treatment. It is hoped thatnurse prescribing will entail enhanced relationships betweenservice user and nurse practitioner, increased frequency ofcontact, increased time for the discussion of treatmentoptions (DoH 2002b) and, consequently, better concordancewith treatment regimens.Since the early 1980s, nurse training in the UK has adopteda psychosocial approach to nursing care, to the detriment ofthe medical model (Bradshaw 2001). This means that nursesattending prescribing training are likely to be able tocommunicate effectively with service users about theirdiagnoses, treatments and expectations, but may lack soundbasic knowledge of biology and pharmacology to enablethem to make confident decisions about medication. Thechallenge for universities is, therefore, to provide nurseprescribers with enough pharmacological training to ensurethat they become confident and competent prescribers.Development of the pharmacology moduleOne university in the West Midlands decided to include asection on pharmacology when mounting the first generalnurse prescribing course in 2001. The drivers for this werethe local healthcare NHS trusts, the Workforce DevelopmentConfederation and the validating committee of the university.Workforce Development Confederations bring together NHSTrusts and HEIs to co-ordinate healthcare training provisionwithin each local area. The NHS requirements were, how-ever, the prime consideration. Material for the section wasdeveloped from information provided by another localuniversity providing training to medical students and nowcovers:• Introduction to receptors and the cell;• Introduction to basic pharmacological principles (phar-macodynamics and pharmacokinetics);• Adverse drug reactions (derived from prescribing for spe-cific patient groups).It soon became clear that the students found the openingsection on the interaction of drugs at the cellular levelchallenging, as it was heavily theoretical. When the emphasischanged and this theory was applied to practice they becamemore confident and enthusiastic. Part of the course develop-ment was therefore planning an increasing emphasis ongetting the students to relate the materials being delivered totheir practice. The students’ ability to interact with theknowledge base was found to be hindered by the barrier ofscientific language and the module set itself a new target ofdemystifying this language. All the training groups comprisednurses from a variety of clinical areas which led to some livelydiscussions not dependent on specific sub-disciplines.Written and verbal feedback from students with a mentalhealth background suggested the need for some furtherextension of the theoretical input. Although the formulary fornurse prescribing is currently limited, the scope of nurses’involvement with prescribing is much more diverse. Many, ifnot all, nurses are charged with the care of patients who havebeen prescribed drugs from outside the nursing formulary. Itis therefore important that the prescribing course shouldprovide some guidance on how to find information about thedrugs most likely to be prescribed in the nurses’ practiceareas.Development of the neuropharmacology moduleIn early 2004, a local NHS Trust requested a neuropharma-cology module in response to feedback from their prescribingmental health nurses who felt that, although they had coveredbasic pharmacological principles in their training, they neededmore specific information about drugs used in mental health,particularly how to select appropriate drug treatments formental health conditions and the impact that drug treatmentsmay have on the body, including side effects. The nursesrecognized that this knowledge would increase their confid-ence, help them to explain to their service users the rationalebehind treatment choices and communicate the potentialimpact that certain drug treatments may have on the serviceuser. Mental health problems cover a range of diseases andsyndromes from mild anxiety states to severe schizophrenia,acute and chronic illness. Pharmacological treatments avail-able range from herbal remedies to tightly monitoredprescription only drugs. There is a certain level of overlapbetween conditions in terms of the drugs used in treatment.Mental healthMental health nurse prescribers? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997993

Page 6

Mental health nurse prescribers were requesting input on themolecular neuropharmacology of the major neurotransmittertype drugs to understand the generation of side-effects better.There was a feeling amongst the nurses that, if they couldunderstand how the drugs worked, and had a clear rationalefor the selection of particular drug treatments, then they couldprepare the service users for the impact of the drug treatmentsin terms of side effects. Furthermore, the nurses felt that theirincreased understanding of the drug treatments wouldenhance their communication with service users about drugchoices, improve concordance and, in some way, control theimpact of the drug on the service users. The provision ofmolecular neuropharmacology teaching was likely to be aschallenging as the basic pharmacological principles hadproved in the original nurse prescribing course. However, itwas found that by using what was now the established routeof focussing learning on practice, encouraging group discus-sion and providing tutor support, the initial fears of thestudents could be overcome and participants quickly becamefamiliar with the language.The influence of substances on the central nervous system(CNS) cannot be underplayed. Over the counter medicationsand herbal remedies can influence a patient’s mental healthstate and polypharmacy must be taken into account whenprescribing. The mental heath nurse needs to be aware of abroad range of substances which could be being used by theirparticular patient group. This is a daunting task for nurseswho are uncertain in their pharmacological knowledge, so itis essential that the psychopharmacology tutor makes themodule relevant, approachable and boosts the confidence ofstudents in the use of scientific language to describe drugfunction and effect.The aim of the neuropharmacology module is to developknowledge of the effects of neuroactive agents on the CNS inhealth and disease. The students are introduced to theinternal environment of the brain and the role of theneurotransmitters acetylcholine (Ach), noradrenaline (NA),c-Amino Butyric Acid (GABA), dopamine, peptides andserotonin. These are highlighted as they are the major targetsof neuropharmacology at present. The assessment for themodule links the knowledge gained in lectures and tutorialsto their clinical area. To prepare for the assessment, a seriesof formative group work events is timetabled to directstudents towards sources of information relating to theirprescribing practice and linked to each of the transmittertypes. There is always time in tutor-led sessions to discussgroup work, so that new concepts can be explored and linkedto the delivered material. This approach enables students tochallenge ideas and concepts within a supportive session atboth the peer and tutor level.Structure of the neuropharmacology moduleThe interactions of drugs with the CNS can arise from avariety of sources. To deliver the material in an accessiblefashion, the content of the module was devised in consulta-tion with a local Primary Care Trust (PCT) and otherinterested bodies based upon the perceived needs of thestudents likely to be taking the module. In the UK, PCTs arelocal organizations which manage and deliver all primarycare services. The outcome of these discussions was a six-daymodule which would fit the university timetables and meetthe needs of the students. Each day was normally brokendown into two lectures, a tutorial/feedback session endingwith a period of directed study (group work), as follows:1 Introduction: Review of Pharmacodynamics and Pharma-cokinetics. Review of the nervous system including thesynapses and receptors. General neuroactive agents such asanaesthetics and anti-epileptic drugs which act on thenerve cell membrane;2 Ach synapses as targets for drug intervention in conditionssuch as Alzheimer’s or Multiple Sclerosis;3 NA synapses as targets for drug intervention in conditionssuch as anxiety, depression, cognition, schizophrenia,asthma, cardiopulmonary disease;4 GABA synapses as targets for drug intervention in anxiety,Huntington’s disease, epilepsy;5 Mono-aminergic (dopamine, serotonin) synapses as a tar-get for drug intervention in bipolar disorder, Parkinson’sdisease, schizophrenia, appetite suppression, depression;6 Peptidergic synapses as a target for drug intervention inpain management and feeding disorders.The following strategies were embedded in these sessions:• To revisit concepts from the nurse prescribing course andconsider the relationships between neurophysiology, dis-ease and pharmacological processes;• To use group work (minimum of two people, maximumof four) to promote student directed learning relevant totheir prescribing practice. Students could choose one ofthe named pharmacologically active agents from thedelivered session and explore via literature research,product sheet interrogation and interrogation of webbased resources such as the BNF (http://www.bnf.org)how this drug would interact with substances in use intheir clinical practice. This approach develops under-standing of polypharmic influences in the specific contextof the prescribing area.The module is assessed by a report negotiated with theindividual student that integrates their particular area ofmental health with current trends in the wider context ofmental health prescribing. This is undertaken when theD Skingsley et al.994? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997

Page 7

student has returned to practice, supported by e-mail contactwith the tutor.DiscussionIt is currently unclear how much pharmacology informationis needed by nurse prescribers to safeguard good prescribingpractice and avoid drug errors. Universities must rise to thechallenge of providing training to ENPFs and supplementarynurse prescribers from different backgrounds and specialities,and therefore with different requirements in terms of phar-macological knowledge. Mental health nurses from oneparticular Trust in the West Midlands were consulted ontheir ongoing training needs and felt that they lackedconfidence in their knowledge of psychopharmacology.Although extra modules such as the one described in thispaper are doubtless helpful, there are funding implications. Itis vital that universities, trusts and local Workforce Devel-opment Confederations maintain a dialogue about nurseprescribing training and practice. Such communication couldensure funding for nurse prescribers who feel that a ‘top-up’module would boost their confidence, and encourage them tomake use of their prescribing qualification. Thought mustalso be given to how organizations can support the academicneeds of nurse prescribers unable to take time-out for extracourses.As nurse prescribing is ‘rolled-out’ across the UK, increas-ing numbers of nurses from specialities based in the acutesector have enrolled on the courses. As with the mental healthnurses, these nurses are likely to want to focus on supple-mentary prescribing issues that are specific to their speciality.However, the prescribing courses that are currently offeredthroughout the UK are still focused around the original fourmain areas of extended independent nurse prescribing: minorillness, minor injuries, palliative care and health promotion.These four areas are clearly primary care focused and reflectthe initial intention of the prescribing initiative to provideextended independent prescribing rights to community,practice and A&E nurses. However, the introduction ofsupplementary prescribing has re-directed the focus of nurseprescribing from primary care and increased the potential fornurses from many different specialities to become prescribers.Unfortunately, the time available for the prescribing coursesdoes not reflect the diversity of the cohorts or allow nurseeducators to focus on the needs of each different speciality.Furthermore, many of the nurse educators available to teachon the prescribing courses stem from primary care back-grounds and undertook the early District Nurse or HealthVisitor prescribing qualifications. As such, there is a lack ofinformation within the core prescribing course that is specificto secondary care. Despite this, many universities do tailortheir course discussions around the membership of eachcohort and course assessments such as Objective StructuredClinical Examinations are increasingly taking place withinclinical practice to ensure their relevance.Although this paper focuses on the ongoing training needsof mental health nurse prescribers, it is unlikely that this issuewill be limited to mental health. Nurses from a variety ofspecialities who are based in the acute sector may find thatthe prescribing course does not provide them with enoughinformation to enable them to prescribe with confidence.Those nurses who do not feel confident in their prescribingability will not prescribe. It is currently unclear how muchpharmacology information each nursing speciality will needto ensure their competency and confidence in their prescri-bing practice. It may be that increasing the amount ofinformation about pharmacology and prescribing serves toincrease the anxiety that nurse prescribers feel about prescri-bing, and provides them with a rationale not to prescribe.The training delivered to nurse prescribers is time limited andis only designed to provide nurses with basic prescribingframeworks, it is not designed to provide nurses with all theinformation that they will need to become effective prescrib-ers. However, the courses do ensure that nurses have theskills to critically appraise literature and participate in theirown ongoing education with the support of their clinicaltutors. One of the advantages of providing a ‘top-up’ module,such as the neuropharmacology module described here, isthat nurses are given dedicated time-out to attend themodule, whereas in practice it may be difficult for them tofind the time to spend on their ongoing education. It isimportant that organizations realize that prescribing trainingdoes not end when the nurse successfully qualifies as aprescriber, and there should be time available for the nurse tospend on their own professional development.This neuropharmacology module was developed in con-sultation with mental health nurse prescribers and theiremployers. The purpose of the module was to improve theunderstanding that mental health nurse prescribers haveabout the drugs they prescribe so that they could improve theinformation and advice they would give to their service users.Despite this perceived need, there is no consideration withinthe module of the ability of the nurse to communicate thisinformation to service users. It is commonly assumed thatnurses attending prescribing courses will already have goodcommunication and assessment skills. However, this is asubject that still warrants attention when considering thequality of information provided to service users who have arange of information needs such as mental health serviceusers. Nurses have traditionally had more time to spendMental healthMental health nurse prescribers? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997995

Page 8

communicating with service users than doctors and this maybe the reason that they have been found to exhibit bettercommunication skills. However, once nurses adopt theirprescribing role, they may find that they have less timeavailable to spend with service users, and thus their commu-nication skills will be increasingly important. It will beinteresting to see whether nurses maintain their ability tocommunicate well with service users when they have areduced consultation time, and whether it would be advan-tageous to include basic information about communicationskills within modules such as this neuropharmacology mod-ule.Feedback from students and nurse prescribers in practice iscrucial to ensure that prescriber training courses are keptup-to-date. Evaluation of courses should not be restricted tothe university environment. The opportunity should be givento nurses to feedback how helpful they have found the courseonce they are practising as prescribers. This will be partic-ularly interesting for this module as it was developed inconsultation with the nurses who attended the course and assuch focussed directly on their perceived needs. Future workwill examine how successfully the extra neuropharmacologymodule supports nurse prescribers in practice, and whethernurses need to re-visit the module on a ‘top-up’ basis. Theinput of service users who have received care from nurseprescribers would also be helpful in the development offuture modules. Although nurses become familiar withscientific terminology as a result of following this course, itis important that they maintain their ability to communicateinformation in a way that is understandable to service users.Service user feedback would ascertain whether this is thecase.It will be interesting to investigate the ongoing trainingneeds of nurse prescribers from different disciplines, whe-ther these are related to their disciplines, or to generalaspects of nurse prescribing. Initial training for nurseprescribers may need to be extended, although it wasalways intended that much of the necessary knowledgewould be gathered through practice and ongoing clinicalteaching and support from clinical educators workingclosely with the nurse prescribers as ‘mentors’. The qualityof this ongoing training is therefore dependent on thequality of the support given by educators and the time theyhave available. It is, therefore, important to ensure that allclinical educators have a clear understanding of their roleprior to undertaking this role. It will also be interesting tosee whether those nurses who have received a ‘top-up’module, such as the neuropharmacology module describedhere, do feel they are more confident in their prescribingpractice than those nurse prescribers who have not receivedany ‘top-up’ information. It may be that increasing theamount of information about pharmacology and prescribingserves to increase nurses’ anxiety about prescribing, andreinforces their perceived need to receive further ‘top-up’modules before they become confident prescribers. Theprovision of ongoing formal support sessions with clinicaltutors and nurse prescribing peers could be an appropriatealternative to ‘top-up’ modules. It will be impossible forprescribing training courses to satisfy the specific demandsof all the specialities who are opting to become supple-mentary prescribers, therefore future nurse prescribers needto consider how they will be able to incorporate theirongoing education within their roles. Nurses may beexpected to extend their role and incorporate their prescri-bing skills without losing other responsibilities or roles. Assuch, there will be little time available for the necessaryongoing professional development required to maintain theirprescribing competencies. This is an important considerationfor both organizations and nurses and will be vital to thesuccess of the prescribing initiative.ContributionsStudy design: EB, PN; data analysis: EB, DS and manuscriptpreparation: EB, PN, DS.ReferencesAudit Commission (2001) A spoonful of sugar: Medicines Manage-ment in NHS hospitals. Audit Commission, London.Benefield WH & Ereshefsky L (1994) The pharmacologic manage-ment of depression. The Journal of Practical Nursing June, 24–34.Bracken P & Thomas P (2002) Time to move beyond the mind-bodysplit. BMJ 325, 1433–1434.Bradley EJ, Campbell P & Nolan P (2005) Nurse prescribers: Whoare they? How do they perceive their role? Journal of AdvancedNursing 51, 439–448.Bradshaw A (2001) The Project 2000 Nurse. Whurr Publishers,London.Brown C (2001) Recovery – wellness: models of hope and empow-erment for people with mental illness. Occupational Therapy inMental Health 17, 1–3.Chapman S (2004) ORCA: a new tool for the review of Medicationin asthma management. Nurse Prescribing 2, 20–24.Chong S & Mythily M (2001) Cardiac effects of psychotropic drugs.Annals of the Academy of Medicine, Singapore 30, 625–631.Department of Health (1999) Making a Difference: strengthening thenursing, midwifery and health visiting contribution to health andhealthcare. Department of Health, London.Department of Health (2001) Essence of Care. Department ofHealth, London.Department of Health (2002a) Supplementary Prescribing. Station-ery Office, London.D Skingsley et al.996? 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 989–997

Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.

"It is hoped that independent nurse prescribing (INP) could contribute to this agenda in the following ways: • enable redesign and streamlining of mental health services; • increase service user access to medicines; • improve information and education provided to service users; • address difficulties with concordance and adherence. Despite the proposed benefits, MHNs have been relatively slow to take on prescribing roles (Gray et al. 2005, Norman et al. 2007) and a number of barriers have been identified including: • generic prescribing training course which does not meet the needs of MHNs (Skingsley et al. 2006); • support during and after training (Bradley et al. 2008); • concerns about keeping prescribing practice within competency (Bradley et al. 2007). Research evidencing that NP is safe and therapeutic in mental health settings has lagged behind service developments , although evidence now exists that suggests SP by MHNs is as safe as that by psychiatrists (Norman et al. 2007) and that service users tend to prefer it (Jones et al. 2007, Norman et al. 2007). "

[Show abstract][Hide abstract]ABSTRACT: ACCESSIBLE SUMMARY: • A growing number of mental heath nurses have trained to become non-medical prescribers but many of them have not actually taken this new role once qualified. • Individual or team formularies can help reduce uncertainty about what each nurse can prescribe and can therefore increase their confidence and willingness to take up new prescribing responsibilities. • Formularies can also be used to enhance communication about medication with service users and promote their involvement in decision making about their own treatment. ABSTRACT: Mental health nurses have been entitled to train to become independent prescribers since May 2006; although the number of trained nurse prescribers seems to have increased steadily, a significant number of them have not actually undertaken prescribing roles on completion of their training or have limited their practice to supplementary prescribing. In order to support existing independent prescribers and to assist those nurses who have trained but are yet to prescribe independently, a mental health trust has piloted the use of individual and team formularies. An evaluation of this project indicated that formularies were well received by existing independent prescribers and were seen as a helpful instrument to support newly qualified and supplementary prescribers in their bid to become independent. Formularies can clarify and formalize each prescriber's area of competence, thus setting clear boundaries, reducing uncertainty and enhancing prescribers' confidence and willingness to take on this new role. Formularies may also be used to enhance communication with service users and further develop shared decision making. Effective procedures need to be in place to ensure formularies are up to date and reflect local practice.

"It is hoped that independent nurse prescribing (INP) could contribute to this agenda in the following ways: • enable redesign and streamlining of mental health services; • increase service user access to medicines; • improve information and education provided to service users; • address difficulties with concordance and adherence. Despite the proposed benefits, MHNs have been relatively slow to take on prescribing roles (Gray et al. 2005, Norman et al. 2007) and a number of barriers have been identified including: • generic prescribing training course which does not meet the needs of MHNs (Skingsley et al. 2006); • support during and after training (Bradley et al. 2008); • concerns about keeping prescribing practice within competency (Bradley et al. 2007). Research evidencing that NP is safe and therapeutic in mental health settings has lagged behind service developments , although evidence now exists that suggests SP by MHNs is as safe as that by psychiatrists (Norman et al. 2007) and that service users tend to prefer it (Jones et al. 2007, Norman et al. 2007). "

[Show abstract][Hide abstract]ABSTRACT: Mental health nurses can now train to become independent prescribers as well as supplementary prescribers. Independent nurse prescribing can potentially help to reorganize mental health services, increase access to medicines and improve service user information, satisfaction and concordance. However, mental health nursing has been slow to undertake prescribing roles, and there has been little work conducted to look at where nurse prescribing is proving successful, and those areas where it is less so. This survey was designed to collect information from directors of nursing in mental health trusts about the numbers of mental health prescribers in England, gather views about prescribing in practice, and elicit intentions with regards to the development of nurse prescribing. In some Trusts, the number of mental health nurse prescribers has increased to the point where wider impacts on workforce, the configuration of teams and services are inevitable. Currently, the way that prescribing is used within different organizations, services and teams varies and it is unclear which setting is most appropriate for the different modes of prescribing. Future work should focus on the impact of mental health nurse prescribing on service delivery, as well as on service users, colleagues and nurses themselves.

"Information specific to specialty areas is not included and is expected to be acquired in practice. Consequently, an MHN can prescribe psychotropic medication without receiving specific formal training in its use (Skingsley et al., 2006) as there is no mandatory requirement for training courses to include detailed input on psychotropic medication. Nationally there is considerable variation in how the implementation of MHN prescribing is being supported (NPC, 2005). "

[Show abstract][Hide abstract]ABSTRACT: What is already known about the topic? To date there are in excess of 400 qualified mental health nurse prescribers in the UK but uptake has been slower than was initially anticipated. Some have suggested that one of the main barriers for implementation is the unsupportive behaviours of psychiatrists. A proportion of the medical profession has expressed grave concerns about the safety of nurse prescribing whereas others appear supportive. What this paper adds Overall both professional groups were in favour of mental health nurse prescribing, although significantly more psychiatrists expressed concerns. General beliefs, impact and uses were inter-related constructs as evidenced by high correlation co-efficients. Psychiatrists in particular were concerned with aspects of clinical and legal responsibility and the appropriate Background: In the United Kingdom, mental health nurses (MHNs) can independently prescribe medication once they have completed a training course. This study investigated attitudes to mental health nurse prescribing held by psychiatrists and nurses. Method: 119 MHNs and 82 psychiatrists working in South-East England were randomly sampled. Participants completed a newly created questionnaire. This included individual item statements with 6-point likert scales to test levels of agreement which were summated into 7 subscales. Results: Psychiatrists had significantly less favourable, albeit generally positive attitudes than MHNs regarding general beliefs (63% vs. 70%, p < 0.001), impact (62% vs. 70%, p < 0.001), uses (60% vs. 71%, p < 0.001), clinical responsibility (69% vs. 62%, p < 0.001) and legal responsibility (71% vs. 64%, p < 0.001). More MHNs than psychiatrists believed that nurse prescribing would be useful in emergency situations for rapid tranquilisation (82% vs. 37%, p < 0.001), and that the consultant psychiatrist should have ultimate clinical responsibility for prescribing by an MHN (42% vs. 28%, p < 0.001). Approximately half of all participants agreed nurse prescribing would create conflict in clinical teams. Conclusions: The majority of both groups were in favour of mental health nurse prescribing, although significantly more psychiatrists expressed concerns. This may be explained by a perceived change in power balance.